Comar Application Form PDF Details

There are many different types of application forms that you may be required to fill out in order to apply for a job. The most common type is the standard employment application form, which is used by most employers. However, there are also other types of application forms, such as the comar application form. The comar application form is specific to certain jobs within the maritime industry, and it is used to assess an applicant's skills and qualifications for those jobs. If you are interested in a career in the maritime industry, then you may need to submit a comar application form alongside your standard employment application. If you don't know how to complete a comar application form, or if you have any other questions about this type of application, then read

QuestionAnswer
Form NameComar Application Form
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namescomar application, comar maryland application, comar application online, maryland application abuse online

Form Preview Example

SITE:

STATE OF MARYLAND

DHMH

Maryland Department of Health and Mental Hygiene

Office of Health Care Quality

Spring Grove Center ● Bland Bryant Building

55 Wade Avenue ● Catonsville, Maryland 21228-4663

Martin O’Malley, Governor Anthony G. Brown, Lt. Governor Joshua M. Sharfstein, M.D., Secretary

APPLICATION PACKET

COMAR 10.47- ALCOHOL AND DRUG ABUSE ADMINISTRATION

Section

Page

Ownership and Emergency Contact Information…………

2

CURRENT Certification Information…………………………….

3

CURRENT Service Level Certification……………………………

4

NEW Level Requests…………………………………………………….

5

Staffing Information…………………………………………………….

6

General Supporting Documentation……………………………

6

Statistics………………………………………………………………………

7

All sections, along with required documentation, are to be completed and returned to the OHCQ - Substance Abuse Unit at the following address:

Office of Health Care Quality

Substance Abuse Certification Unit

Bland Bryant Building – Spring Grove Hospital Center

55 Wade Avenue

Catonsville, MD 21228

Please read and familiarize yourself with COMAR 10.47.Alcohol and Drug Abuse Administration, dated August 2008, prior to completing this application.

Please direct inquiries concerning this application and the application process to the Substance Abuse Certification Unit:

Substance Abuse Unit (410) 402-8095

Thank you for your attention to these matters.

Toll Free 1-877-4MD-DHMH TTY for Disabled Maryland Relay Service 1-800-735-2258

WEBwww.dhmh.state.md.us

P r o g r a m , O w n e r s h i p a n d E m e r g e n c y C o n t a c t

I n f o r m a t i o n

Ownership Information

Legal Name of Business/Owner:

[ O er is defi ed as a so eo e ho o s is legal possessor of a usi ess; a proprietor. Certifi atio s shall e

issued in the legal name of the business/owner)

Mailing Address of Business/Owner:

City or Town of Business/Owner:

Zip Code

Business/O

er’s We

Site Address:

 

Busi

ess/O

er’s E ail:

 

 

Busi

ess/O

er’s Pho

e Nu

er:

 

Busi

ess/O

er’s Fa

Nu

er:

 

Type of Business Organization/Government Agency:

[ Busi ess Orga izatio ” is defined as one of the six forms of business organizations for federal tax purposes.]

Business Organization

Government Agency Type

I.

Sole Proprietorship

VII. Government Agency

 

 

 

 

II.

**Corporation

a)

City

 

 

 

 

III.

Partnership

b)

State

IV.

S-Corporation

c)

Federal

V.

Trust

 

 

 

 

 

VI. **Non-Profit

 

 

**Non-Profit Corporation requires submission of IRS Form 990

 

Program Information

 

 

Current Program or Trade Name:

 

 

 

[ Trade Na e” is defi ed as The a

e or style u der hi h a o er does usi ess. ]

Program Street Address:

 

 

 

Program Town or City:

Zip Code

 

 

Program Web Site:

 

 

 

Program Email:

 

 

 

Program Phone Number:

 

Program Fax Number:

 

County of Operation:

 

National Provider Identification:

 

(If services are contracted with another State, Federal or Local government department, please attach a copy of the Contract Service Agreement to this application)

Emergency Contact

Must Have Access to Patient Records

Emergency Contact Name:

[ E

erge

y Co ta t is defi ed as: A i di idual ho has a ess to patie t re ords a d a

pro ide patie t o ta t

information at all times. (see COMAR 10.47.01.03D (1)(a)(i).]

 

 

 

Emergency Contact Home Address:

 

Emergency Contact City or Town:

Zip Code:

E

erge

Co

ta t’s Cell Pho e:

 

 

E

erge

Co

ta t’s Offi e Pho

e:

 

E

erge

Co

ta t’s Ho

e Pho

e:

 

E

erge

Co

ta t’s E

ail:

 

 

2

C U R R E N T C e r t i f i c a t i o n I n f o r m a t i o n

The current certification number is:

[A Curre t Certifi atio Nu er” is defined as the registration or certification number issued to the program after the last survey and formally shown on the progra ’s Ge eral Certifi ate of Appro al issued ADAA.]

The current certification for this Program expires on:

[ Certifi atio E piratio ” is defi ed as the e piratio date fou d o the progra ’s Ge eral Certifi ate of Appro al issued by ADAA.]

Not Applicable (please check)

[ Not Appli a le” would apply on applications for initial program applications, i.e., those programs that have not previously been issued a program certification number by ADAA.]

Type of Certification Requested on this Application

Please Note: This application may be used for combinations of certification requests, e.g. a renewal application may also include a change in program location or an addition or deletion of service level. Please check all that apply. However, a

separate application packet must be completed for each physical site.

Initial Certification Request (SEE COMAR 10.47.04.04A)

[A I itial Certifi atio ” is defined as an application submitted by an owner for the first certification of a program that has never previously been certified by the ADAA. This certification is valid for a period not to exceed six months.]

Renewal of General Certification Request (SEE COMAR 10.47.04.04C)

[A Re e al of General Certificationis defined as a certification which is provided to a currently certified program whose certification period is about to expire or has expired and the program is not requesting a change in program service level.]

Change of Program Location Certification Request (SEE COMAR 10.47.04.03G & 10.47.04.04D (6)

[A Cha ge of Progra Lo atio Certifi atio ” is defined as a request for certification of a program that has changed the physical location of its place of business, i.e. the site where the program provides its services to patients or a change in location of its administrative offices.]

Change in Service Levels Request (SEE COMAR 10.47.04.03D)

[A

Cha

ge i

“er i e Le els

is defined as the addition or deletion of a program service level. (see COMAR

10.47.02.03 thru 10.47.02.11)]

 

 

Change in Program Ownership (SEE COMAR 10.47.04.03G)

[A

Cha

ge i

Progra O

ership is defi ed a

ir u sta es i hi h the o ership of the pre iously

certified program is sold, transferred or reassigned.]

Initial or Renewal Certification of Opioid Maintenance Therapy Program(s) (SEE COMAR 10.47.02.11)

An application fee of $700 is required with the initial application and at recertification, if the program provides opioid maintenance therapy (Opioid Maintenance Therapy Programs). Checks shall be payable to DHMH/OHCQ.

REV. 06/17/2013

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C U R R E N T S e r v i c e L e v e l C e r t i f i c a t i o n

(See COMAR 10.47.02.03 thru 10.47.02.11 & 10.47.03.03 thru 10.47.03.07). Please check all that apply and write

under each category the # of adults, adolescents and/or children you serve.

Outpatient Services

Adults

Adolescents

Children

Level 0.5 Early Intervention

Level 0.5 Early Intervention: DWI Ed

Level I Outpatient

Level II.1 Intensive Outpatient

Level II.5 Partial Hospitalization

Residential Services

Adults

Adolescents

Children

Level III.1 Clinically Managed Low Intensity Residential

Level III.3 Clinically Managed Medium Intensity

Level III.5 Clinically Managed High Intensity Residential

Level III.7 Medically Monitored Intensive Inpatient Treatment

Detoxification Services

Adults

Adolescents

Children

 

 

 

Level I.D Ambulatory Detoxification w/o Extended On-site Monitoring

Level II.D Ambulatory Detoxification with Extended On-site Monitoring

Level III.2-D Clinically Managed Residential Detoxification

Level III.7-D Medically Monitored Inpatient Detoxification

Opioid Maintenance Therapy

Adults

Adolescents

OMT - Opioid Maintenance Therapy

**OMT.D – Only Opioid Maintenance Therapy Detoxification

**(Check only if a State & Federally Approved Opioid Treatment Program)

Correctional Service Levels

Select if a Specific Program Requirement

Correctional Level I

Correctional Level II.1

Correctional Level II.5

Correctional Level III.1

Correctional Level III.5

REV. 06/07/11

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NEW Level Requests

ONLY COMPLETE IF ADDING OR CHANGING LEVELS

New Service Level Certification Requests: (See COMAR 10.47.02.03 thru 10.47.02.11 & 10.47.03.03 thru 10.47.03.07. Please check all that apply and write under each category the # of adults, adolescents and/or children to be served.)

Outpatient Services

Adults

Adolescents

Children

Level 0.5 Early Intervention

Level 0.5 Early Intervention: DWI Ed

Level I Outpatient

Level II.1 Intensive Outpatient

Level II.5 Partial Hospitalization

Residential Services

Adults

Adolescents

Children

Level III.1 Clinically Managed Low Intensity Residential

Level III.3 Clinically Managed Medium Intensity Residential

Level III.5 Clinically Managed High Intensity Residential

Detoxification Services

Adults

Adolescents

Children

Level I.D Ambulatory Detoxification w/o Extended On-site Monitoring

Level II.D Ambulatory Detoxification with Extended On-site Monitoring

Level III.2-D Clinically Managed Residential Detoxification

Level III.7-D Medically Monitored Inpatient Detoxification

Opioid Maintenance Therapy

Adults

Adolescents

OMT - Opioid Maintenance Therapy

**OMT.D ONLY Opioid Maintenance Therapy Detoxification

**(Check only if a State & Federally Approved Opioid Treatment Program)

Correctional Service Levels

(Select if a specific program requirement)

Correctional Level I

Correctional Level II.1

Correctional Level II.5

Correctional Level III.1

Correctional Level III.5

This program will provide services in the following treatment settings: (Please check all that apply)

Maryland Division of Correction

Local Detention Center

REV. 06/07/11

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S t a f f i n g I n f o r m a t i o n

Please Provide The Listed Information (As Required By COMAR 10.47.01.06) For These Required Staff Positions.

Sponsor

Information required for Opioid Maintenance Therapy Programs only - 42 CFR Part 8.2

Name of Sponsor:

Mailing Address of Sponsor:

City or Town of Sponsor:

Spo

sor’s E-mail Address:

 

 

Spo

sor’s Pho e Nu er:

 

 

Program

Progra Ad

i istrator’s Name:

 

Medi al Dire tor’s Name:

 

 

Cli i al Super

isor’s Na e:

 

 

G e n e r a l S u p p o r t i n g D o c u m e n t a t i o n

Please Provide With This Application The Following Supporting Documentation

Governing Body

A roster of the e er or e ers of the progra ’s governing body as required by COMAR 10.47.01.03. The roster

shall have the name and mailing address of all members.

(A Go er i g Bod ” means the organizational structure that is responsible for establishing policy, maintaining quality care, and

providing management and planning for the program.

Organizational Chart

The chart shall show schematically the staff positions maintained by the program, detailing lines of authority and

responsibility, and the individual names of staff members currently employed in those positions including all clinical staff

employees.

REV. 06/07/11

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R e q u i r e d S t a t i s t i c s

The number of patients receiving services at the time of the application:

(The u er of patie ts re ei i g ser i es is defi ed as the TOTAL u er of patients receiving program services on the day the application is submitted to OHCQ irrespective of the type of services those patients are receiving. An application, for example, requesting an Initial Certification would have a patient census of zero at the time of the application submittal.)

This Program Will Provide The Following Language/Communication Services

 

Please Check all that Apply

 

 

 

 

 

Spanish

 

 

Services for the Hearing Impaired

 

 

 

 

 

American Sign Language

 

 

Other Language service(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This Program Will Serve

 

 

Adolescents (12-17 years of age)

Adult Females

 

 

Adult Males

Pregnant Women

 

 

 

Women with Children

 

This program will receive public funds from the following sources

 

Please Check all that Apply

 

 

Medicaid

Start Up Funds

 

 

Medicare

Federal Funds

 

 

Medical Assistance

Local Government Funds

(Please note: If any of the above funding sources are checked please contact ADAA to determine reporting

requirements!)

Mental Health

Check Only One

Co-Occurring Enhanced (refer to the American Society of Addiction Medicine-Patient Placement Criteria)

Co-Occurring Capable (Refer to ASAM-PC)

REV. 06/07/11

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